Book Reflection: When Breath Becomes Air

Right after I finished this book, I went on a walk and started listening to a few podcasts that Paul Kalanithi's wife, Lucy Kalanithi, gave. As I was walking and listening to the part where Paul passed away, I actually got hit by a scooter. Not hit as in full force, but it scraped my shins, and the driver quickly drove off.

I had this thought that I might have almost died while listening to a story about death. It definitely added to everything I was already feeling after reading this book.

I had bawled my eyes out more than once while reading it. I was also in the luteal phase of my cycle, which is the most sensitive and receptive time for me. So hormones definitely played a role, but so did the absolute mastery Paul seems to have of writing.

I was completely drawn in right from the beginning because I could relate to so much of how he sees and experiences life. I could relate to the existentialism he constantly exuded; I find myself constantly asking these questions too. What I will say is that he has inspired me to write a book myself at some point. He came across as a powerful supernova that might have lived a short life but impacted the people and systems around him for years.

I procrastinated for over a week before writing this because I wanted it to match the level and depth of the book. But I quickly realized that will probably not happen anytime soon, because this is a book written in an urgent, life-or-death, final-chance type of circumstance. Living our lives, or writing things, at that level is rarely possible without a similar sense of doom.

But I figured I would write something anyway. Trying, as Paul mentions throughout, is the only thing we can do in this lifetime. I don't think I will be able to summarize, or even fully articulate, what he wanted to express in this book. And honestly, I don't really want to. There are books where summarizing feels like flattening them. So instead, I wanted to leave here all the quotes and highlights that stayed with me. There are a lot. An absurd amount, actually. This is the most I have ever highlighted in a book. I am surrendering to the highlights.

I also don't think what I choose to highlight is neutral; it says something about what resonated with me. Selection is interpretation. And because my experience of this book was excessive, associative, emotional, and nonlinear, letting this post be a little excessive and associative feels more faithful to the truth of how I experienced it.

But you can read through them if you would like:

Listen to Paul. In the silences between his words, listen to what you have to say back.

==========

Nabokov, for his awareness of how our suffering can make us callous to the obvious suffering of another.

==========

If the unexamined life was not worth living, was the unlived life worth examining?

==========

Her capacity to love was barely finite, and a lesson to me

==========

Like a premature lung, I felt unready for the responsibility of sustaining life.

==========

“You think that’s bad?” she continued. “Most mothers with stillborns still have to go through labor and deliver. Can you imagine? At least these guys had a chance.”

==========

Surely intelligence wasn’t enough; moral clarity was needed as well. Somehow, I had to believe, I would gain not only knowledge but wisdom, too.

==========

I realized that the questions intersecting life, death, and meaning, questions that all people face at some point, usually arise in a medical context.

==========

Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?

==========

treat all my paperwork as patients

==========

Openness to human relationality does not mean revealing grand truths from the apse; it means meeting patients where they are, in the narthex or nave, and bringing them as far as you can.

==========

I don’t think I ever spent a minute of any day wondering why I did this work, or whether it was worth it.

==========

The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burdens are what make medicine holy and wholly impossible: in taking up another’s cross, one must sometimes get crushed by the weight.

==========

The most rigorous and prestigious path is that of the neurosurgeon-neuroscientist.

==========

Science, I had come to learn, is as political, competitive, and fierce a career as you can find, full of the temptation to find easy paths.

==========

I’d never met someone so successful who was also so committed to goodness.

==========

He paused. “Paul,” he said, “do you think my life has meaning? Did I make the right choices?”

==========

How little do doctors understand the hells through which we put patients.

==========

The pain of failure had led me to understand that technical excellence was a moral requirement.

==========

Neurosurgery requires a commitment to one’s own excellence and a commitment to another’s identity.

==========

It felt to me as if the individual strands of biology, morality, life, and death were finally beginning to weave themselves into, if not a perfect moral system, a coherent worldview and a sense of my place in it.

==========

For us, for our patients: it is our fate as living, breathing, metabolizing organisms.

==========

Even if you are perfect, the world isn’t.

==========

You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.

==========

he who should teach men to die would at the same time teach them to live.

==========

I told her to remarry, that I couldn’t bear the thought of her being alone.

==========

One chapter of my life seemed to have ended; perhaps the whole book was closing.

==========

life had been building potential, potential that would now go unrealized.

==========

Death, so familiar to me in my work, was now paying a personal visit.

==========

Go back to work? What is she talking about? Is she delusional?

==========

like a runner crossing the finish line only to collapse, without that duty to care for the ill pushing me forward, I became an invalid.

==========

Our financial plan, which a few days before had banked on my income increasing sixfold in the next year, now looked precarious, and a variety of new financial instruments seemed necessary to protect Lucy.

==========

began to realize that coming in such close contact with my own mortality had changed both nothing and everything.

==========

The fact of death is unsettling. Yet there is no other way to live.

==========

It occurred to me that my relationship with statistics changed as soon as I became one.

==========

What patients seek is not scientific knowledge that doctors hide, but existential authenticity each person must find on her own. Getting too deeply into statistics is like trying to quench a thirst with salty water.

==========

In truth, cancer had helped save our marriage.

==========

“Don’t you get it?” she said, taking my hand in hers. “If we’re the best at this, that means it doesn’t get better than this.”

==========

what it meant to nurture a new life while mine faded.

==========

struggled, while facing my own death, to rebuild my old life—or perhaps find a new one.

==========

what my goals were. I picked two: riding my bike and going for a run.

==========

Was this a victory or a defeat?

==========

As a doctor, I was an agent, a cause; as a patient, I was merely something to which things happened.

==========

every statistic I cited she rebuffed with a reminder to focus on my values.

==========

Flush in the face of mortality, many decisions became compressed, urgent and unreceding.

==========

If human relationality formed the bedrock of meaning, it seemed to us that rearing children added another dimension to that meaning.

==========

“What are you most afraid or sad about?” she asked me one night as we were lying in bed. “Leaving you,” I told her.

==========

“Don’t you think saying goodbye to your child will make your death more painful?” “Wouldn’t it be great if it did?” I said. Lucy and I both felt that life wasn’t about avoiding suffering.

==========

After so many years of living with death, I’d come to understand that the easiest death wasn’t necessarily the best.

==========

We decided to have a child. We would carry on living, instead of dying.

==========

Even in having children in this new life, death played its part.

==========

Yet being there merely heightened the surreal contrast of what my life was now. I was surrounded by success and possibility and ambition, by peers and seniors whose lives were running along a trajectory that was no longer mine, whose bodies could still tolerate standing for a gruelling eight-hour surgery.

==========

Lost in a featureless wasteland of my own mortality, and finding no traction in the reams of scientific studies, intracellular molecular pathways, and endless curves of survival statistics, I began reading literature again:

==========

acquiring rich experiences, then retreating to cogitate and write about them. I needed words to go forward. And so it was literature that brought me back to life during this time.

==========

got out of bed and took a step forward, repeating the phrase over and over: “I can’t go on. I’ll go on.”

==========

knowing that even if I’m dying, until I actually die, I am still living.

==========

(People often ask if it is a calling, and my answer is always yes. You can’t see it as a job, because if it’s a job, it’s one of the worst jobs there is.)

==========

Death may be a one-time event, but living with terminal illness is a process.

==========

The truth that you live one day at a time didn’t help: What was I supposed to do with that day?

==========

I had gone from being unable to believe I could be a surgeon to being one, a transformation that carried the force of religious conversion.

==========

As furiously as I had tried to resist it, I realized that cancer had changed the calculus.

==========

The curse of cancer created a strange and strained existence, challenging me to be neither blind to, nor bound by, death’s approach.

==========

You have to figure out what’s most important to you.

==========

the physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.

==========

Emma hadn’t given me back my old identity. She’d protected my ability to forge a new one. And, finally, I knew I would have to.

==========

Surely enlightened reason offered a more coherent cosmos.

==========

I spent a good chunk of my twenties trying to build a frame for such an endeavor.

==========

to make science the arbiter of metaphysics is to banish not only God from the world but also love, hate, meaning—to consider a world that is self-evidently not the world we live in.

==========

It is to say, though, that if you believe that science provides no basis for God, then you are almost obligated to conclude that science provides no basis for meaning and, therefore, life itself doesn’t have any.

==========

Yet the paradox is that scientific methodology is the product of human hands and thus cannot reach some permanent truth.

==========

it also makes scientific knowledge inapplicable to the existential, visceral nature of human life, which is unique and subjective and unpredictable.

==========

No system of thought can contain the fullness of human experience.

==========

Human knowledge is never contained in one person.

==========

Once again, I had traversed the line from doctor to patient, from actor to acted upon, from subject to direct object.

==========

As in most modern narratives, a character’s fate depended on human actions, his and others.

==========

I hadn’t ever considered that I could release myself from the responsibility of my own medical care.

==========

There we were, doctor and patient, in a relationship that sometimes carries a magisterial air and other times, like now, was no more, and no less, than two people huddled together, as one faces the abyss.

==========

Feeling her weight in one arm, and gripping Lucy’s hand with the other, the possibilities of life emanated before us.

==========

Looking out over the expanse ahead, I saw not an empty wasteland but something simpler: a blank page on which I would go on.

==========

Perhaps later than I think, but certainly sooner than I desire.

==========

The most obvious might be an impulse to frantic activity: to “live life to its fullest,” to travel, to dine, to achieve a host of neglected ambitions.

==========

it also limits your energy, vastly reducing the amount you can squeeze into a day.

==========

Graham Greene once said that life was lived in the first twenty years and the remainder was just reflection.

==========

Everyone succumbs to finitude.

==========

Most ambitions are either achieved or abandoned; either way, they belong to the past.

==========

Money, status, all the vanities the preacher of Ecclesiastes described hold so little interest: a chasing after wind, indeed. Yet one thing cannot be robbed of her futurity: our daughter, Cady. I hope I’ll live long enough that she has some memory of me.

==========

There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past.

==========

When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing.

==========

You left me boundaries of pain Capacious as the sea, Between eternity and time, Your consciousness and me.

==========

We hosted cozy dinner parties, held each other at night, and delighted in our daughter’s bright eyes and calm nature.

==========

He used to love my breakfast sandwiches—egg, sausage, and cheese on a roll—but with his waning appetite we’d changed to eggs and toast, then just eggs, until even those became intolerable.

==========

Although Paul accepted his limited life expectancy, neurologic decline was a new devastation, the prospect of losing meaning and agency agonizing.

==========

My heart swelled even as I steeled myself, anticipating his suffering, worrying that he had only weeks left—if that. I envisioned his funeral as we held hands. I didn’t know that Paul would die within days.

==========

Paul sang to Cady and bounced her gently in his lap.

==========

The manuscript for this book was only partially finished, and Paul now knew that he was unlikely to complete it—unlikely to have the stamina, the clarity, the time.

==========

We’d continue to absorb the recent painful news, share the sorrow, savor our time together.

========== Paul napped comfortably in the afternoon, but he was gravely ill.

==========

I already missed him.

==========

Paul on a gurney this time, his parents close behind us, he turned toward me and whispered, “This might be how it ends.” “I’m here with you,” I said.

==========

He observed. He understood, as a physician, the ominous test results.

==========

The only remaining intervention would be for Paul to be intubated—put on a ventilator. Was that what he wanted?

==========

Could the sudden respiratory failure be reversed?

==========

he could choose “comfort care,” though death would come more surely and swiftly. “Even if I make it through this,” he said, thinking of the cancer in his brain, “I’m not sure I see a future that includes meaningful time.”

==========

I napped briefly in an adjacent room, hoping to preserve my mental strength, knowing that the following day might be the hardest of my life.

==========

However, I said I would do everything possible to take him home if that was most important to him, nodding that yes, comfort care might be the direction we were headed.

==========

“He doesn’t want a Hail Mary,” I said. “If he doesn’t have a chance of meaningful time, he wants to take the mask off and hold Cady.”

==========

his voice soft but unwavering, “I’m ready.” Ready, he meant, to remove the breathing support, to start morphine, to die.

==========

Tears glistened in Paul’s eyes.

==========

He asked us to ensure that his manuscript be published in some form. He told me a last time that he loved me.

==========

because of the example of bravery you set.”

==========

“Go in peace, my brother.”

==========

my love for Paul deepening as I watched him lean in and listen closely to my grandfather’s whispered requests.

==========

Twenty-two months ago, we’d cried in a bed on another floor of this same hospital as we learned of Paul’s cancer diagnosis.

==========

thought of our cozy bed empty at home, remembered falling in love in New Haven twelve years earlier, surprised right away by how well our bodies and limbs fit together, and thought of how ever since, we’d both slept best when entwined.

==========

He was breathing steadily but shallowly, and he appeared comfortable.

==========

I asked him whether he needed more morphine, and he nodded yes, his eyes closed.

==========

For more than nine hours, Paul’s family—his parents, brothers, sister-in-law, daughter, and I—sat vigil as Paul, unconscious, now drew increasingly halting, infrequent breaths, his eyelids closed, his face unburdened.

==========

“Thank you for loving me.”

==========

each other’s with concern, steeped in the preciousness and pain of this time, our last hours all together.

==========

I held her cheek to Paul’s, tufts of their matching dark hair similarly askew, his face serene, hers quizzical but calm, his beloved baby never suspecting that this moment was a farewell.

==========

Just before nine o’clock, his lips apart and eyes closed, Paul inhaled and then released one last, deep, final breath.

==========

When Breath Becomes Air is, in a sense, unfinished, derailed by Paul’s rapid decline, but that is an essential component of its truth, of the reality Paul faced.

==========

He was determined to keep writing. This book carries the urgency of racing against time, of having important things to say.

==========

He wanted to help people understand death and face their mortality.

==========

He wanted to help people understand death and face their mortality. Dying in one’s fourth decade is unusual now, but dying is not.

==========

That’s what I’m aiming for, I think. Not the sensationalism of dying, and not exhortations to gather rosebuds, but: Here’s what lies up ahead on the road.”

==========

He traversed it bravely. Paul’s decision not to avert his eyes from death epitomizes a fortitude we don’t celebrate enough in our death-avoidant culture.

==========

He spent much of his life wrestling with the question of how to live a meaningful life, and his book explores that essential territory. “Always the seer is a sayer,” Emerson wrote.

==========

Writing this book was a chance for this courageous seer to be a sayer, to teach us to face death with integrity.

==========

His cancer diagnosis was like a nutcracker, getting us back into the soft, nourishing meat of our marriage.

==========

We each joked to close friends that the secret to saving a relationship is for one person to become terminally ill.

==========

will share your joy and sorrow / Till we’ve seen this journey through.” When Paul told me, immediately after his diagnosis, to remarry after he died, it exemplified the way he would, throughout his illness, work hard to secure my future.

==========

At the same time, I worked hard to secure his present, to make his remaining time the best it could be, tracking and managing every symptom and aspect of his medical care—the most important doctoring role of my life—while supporting his ambitions, listening to his whispered fears as we embraced in the safety of our darkened bedroom, witnessing, acknowledging, accepting, comforting.

==========

He knew he would never be alone, never suffer unnecessarily.

==========

“It’s the only way I know how to breathe.”

==========

On those afternoons, our living room felt like a small, safe village.

==========

for having risen to meet each other at a time when absolute trust and acceptance were required. Although these last few years have been wrenching and difficult—sometimes almost impossible—they have also been the most beautiful and profound of my life, requiring the daily act of holding life and death, joy and pain in balance and exploring new depths of gratitude and love.

==========

the future he had planned and forge a new one. He cried on the day he was diagnosed. He cried while looking at a drawing we kept on the bathroom mirror that said, “I want to spend all the rest of my days here with you.”

==========

He let himself be open and vulnerable, let himself be comforted. Even while terminally ill, Paul was fully alive; despite physical collapse, he remained vigorous, open, full of hope not for an unlikely cure but for days that were full of purpose and meaning.

==========

Here he is as a doctor, as a patient, and within a doctor-patient relationship.

==========

Not fully captured in these pages are Paul’s sense of humor—he was wickedly funny—or his sweetness and tenderness, the value he placed on relationships with friends and family.

==========

this was what he wrote when he needed to write it.

==========

is the beautiful, focused man he was in his last year, the Paul who wrote this book—frail but never weak.

==========

he once said that he found poetry more comforting than Scripture—and his ability to forge from his life a cogent, powerful tale of living with death.

==========

“The good news is I’ve already outlived two Brontës, Keats, and Stephen Crane. The bad news is that I haven’t written anything.”

==========

from one passionate vocation to another, from husband to father, and finally, of course, from life to death, the ultimate transformation that awaits us all.

==========

while he wrote this book, an act that allowed him to live with hope, with that delicate alchemy of agency and opportunity that he writes about so eloquently, until the very end.

==========

“We shall rise insensibly, and reach the tops of the everlasting hills, where the winds are cool and the sight is glorious.”

==========

like death, like grief—but there is beauty in all of it, and I think this is good and right.

==========

It’s just as good a use for the flowers as any, and one Paul would have liked.

==========

the inextricability of life and death, and the ability to cope, to find meaning despite this, because of this. What happened to Paul was tragic, but he was not a tragedy.

==========

Paul is gone, and I miss him acutely nearly every moment, but I somehow feel I’m still taking part in the life we created together.

==========

“but one of its regular phases—like the honeymoon. What we want is to live our marriage well and faithfully through that phase too.”

==========

my love goes on—lives on—in a way I’d never expected.

==========

I understand that had he lived, he would have made great contributions as a neurosurgeon and neuroscientist.

==========

Instead, this book is a new way for him to help others, a contribution only he could make.

==========

This was the life he was given, and this is what he made of it. When Breath Becomes Air is complete, just as it is.

==========

Please know that all the wonderful things people are saying now about your dad are true. He really was that good and that brave.”

==========

Paul’s decision to look death in the eye was a testament not just to who he was in the final hours of his life but who he had always been. For much of his life, Paul wondered about death—and whether he could face it with integrity. In the end, the answer was yes. I was his wife and a witness.

==========

whose fierce support and nurturing gave Paul the confidence that he could write an important book.

==========

believe Paul died knowing that these words would make their way into the world.

==========

am grateful to Emily Rapp for her willingness to meet me in my grief and coach me through the epilogue, teaching me, as Paul did, what a writer is and why writers write. Thank you to all who have supported our family, including the readers of this book.

==========

He is survived by his large, loving family, including his wife, Lucy, and their daughter, Elizabeth Acadia.

========== Oof, if you got this far, I have so much respect for you. The focus is admirable. Maybe we should be friends :) Thank you for reading. Consider subscribing to my email list so the posts come directly to you.